I Hate You--Don't Leave Me: Understanding the Borderline Personality

by Jerold J. Kreisman

The diagnosis of BPD is confirmed when at least five of the following nine criteria are present.

The SET-UP system evolved as a structured framework of communication with the borderline in crisis. During such times, communication with the borderline is hindered by his impenetrable, chaotic internal force field, characterized by three major feeling states: terrifying aloneness, feeling misunderstood, and overwhelming helplessness. As a result, concerned individuals are often unable to reason calmly with the borderline and instead are forced to confront outbursts of rage, impulsive destructiveness, self-harming threats or gestures, and unreasonable demands for caretaking. SET-UP responses can serve to address the underlying fears, dilute the borderline conflagration, and prevent a “meltdown” into greater conflict. Although SET-UP was developed for the borderline in crisis, it can also be useful for others who require concise, consistent communication, even when not in crisis.

SET Communication “SET”—Support, Empathy, Truth—is a three-part system of communication (see Figure 5-1). During confrontations of destructive behavior, important decision-making sessions, or other crises, interactions with the borderline should invoke all three elements. UP stands for Understanding and Perseverance—the goals that all parties try to achieve. The S stage of this system, Support, invokes a personal, “I” statement of concern. “I am sincerely worried about how you are feeling” is an example of a Support statement. The emphasis is on the speaker’s own feelings and is essentially a personal pledge to try to be of help. With the Empathy segment, one attempts to acknowledge the borderline’s chaotic feelings with a “You” statement: “How awful you must be feeling.” It is important not to confuse empathy with sympathy (“I feel so sorry for you . . .”), which may elicit rage over perceived condescension. Also, Empathy should be expressed in a neutral way with minimal personal reference to the speaker’s own feelings. The emphasis here is on the borderline’s painful experience, not the speaker’s. A statement like “I know just how bad you are feeling” invites a mocking rejoinder that, indeed, you do not know, and only aggravates conflict. FIGURE 5-1 The T statement, representing Truth or reality, emphasizes that the borderline is ultimately accountable for his life and that others’ attempts to help cannot preempt this primary responsibility. While Support and Empathy are...

Support statements must convey that caring is constant, unconditional. Unfortunately, the borderline has difficulty grasping that she does not need to earn acceptance continuously. She is in constant fear that Support could be withdrawn if at any point she displeases.

The Need for Consistency All Truth statements must, indeed, be true. For the borderline, already living in a world of inconsistencies, it is much worse to make idle threats about the unenforced consequences of an action than to passively allow inappropriate behaviors to continue.

Although the SET-UP principles were developed for working with borderline patients, they can be useful for dealing with others. When communication is stalled, SET-UP can help focus on messages that are not being successfully transmitted. If an individual feels that he is not supported or respected, or that he is misunderstood, or if he refuses to address realistic problems, specific SET steps can be taken to reinforce these flagging areas. In today’s complex world, a clear set of communication principles that includes both love and reason are necessary to overcome the tribulations of borderline chaos. Productive communication requires Understanding and Perseverence. Understanding the underlying dynamics of the communication and the needs of the partner reinforce SET principles. Perseverance is necessary to effect change. For many borderlines, having a consistent, unflappable figure in their lives (neighbor, friend, therapist) may be one of the most important requirements for healing. Such a figure may contribute little except for his consistency and acceptance (in the face of frequent provocations), yet furnish the borderline with a model of constancy in the borderline’s otherwise chaotic world.

dialectic

Little by little, Elizabeth started to heal. She felt “the curtains raising.” She compared the feeling to looking for a valuable antique in a dark attic filled with junk—she knew that it was in there somewhere but couldn’t see it because of all the clutter. When she finally did spot it, she couldn’t get to it because it was “buried under a pile of useless garbage.” But now and then she could see a clear path to the object, as if a flash of lightning had illuminated the room for a brief instant.

“Change is real hard work!” Elizabeth often noted. It requires conscious retreat from unhealthy situations and the will to build healthier foundations. It entails coping with drastic interruption of a long-established equilibrium.

many patients who seemed just beyond the reach of psychoanalysis. The Kleinians focused on psychological dynamics as opposed to biological-constitutional factors. The term borderline was first coined by Adolph Stern in 1938 to describe a group of patients who did not seem to fit into the primary diagnostic classifications of “neuroses” and “psychoses.”2 These individuals were obviously more ill than neurotic patients—in fact, “too ill for classical psychoanalysis”—yet they did not, like psychotic patients, continually misinterpret the real world. Though, like neurotics, they displayed a wide range of anxiety symptoms, neurotic patients usually had a more solid, consistent sense of identity and used more mature coping mechanisms. Throughout the 1940s and 1950s, other psychoanalysts began to recognize a population of patients who did not fit existing pathological descriptions. Some patients appeared to be neurotic or mildly symptomatic, but when they engaged in traditional psychotherapy, especially psychoanalysis, they “unraveled.” Similarly, hospitalization would also exacerbate symptoms and increase the patient’s infantile behavior and dependency on the therapist and hospital. Other patients would appear to be severely psychotic, often diagnosed schizophrenic, only to make a sudden and unexpected recovery within a very short time. (Such dramatic improvement is inconsistent with the usual course of schizophrenia.) Still other patients exhibited symptoms suggestive of depres...

In 1953, Robert Knight revitalized the term borderline in his consideration of “borderline states.”8 He recognized that, even though certain patients presented markedly different symptoms and were categorized with different diagnoses, they were expressing a common pathology. After Knight’s work was published, the term borderline became more popular, and the possibility of using Stern’s general borderline concept as a diagnosis became more acceptable. In 1968, Roy Grinker and his colleagues defined four subtypes of the borderline patient: (1) a severely afflicted group who bordered on the psychotic; (2) a “core borderline” cluster with turbulent interpersonal relationships, intense feeling states, and loneliness; (3) an “as-if” group easily influenced by others and lacking in stable identity; and (4) a mildly impaired set with poor self-confidence and bordering on the neurotic end of the spectrum.9 Yet,

Variable Sense of Reality Like neurotics, borderlines retain contact with reality most of the time; however, under stress the borderline can regress to a brief psychotic state. Marjorie, a twenty-nine-year-old married woman, sought therapy for increasing depression and marital disharmony. An intelligent, attractive woman, Marjorie related calmly throughout her initial eight sessions. She eagerly assented to a joint interview with her husband, but during the session she turned uncharacteristically loud and belligerent. Dropping her facade of self-control, she began to berate her husband for alleged infidelities. She accused her therapist of taking her husband’s side (“You men always stick together!”) and accused both of engaging in a conspiracy against her. The sudden transformation from a relaxed, mildly depressed woman to a raging, paranoid one is quite characteristic of the kind of rapidly shifting borders of reality observed in the borderline. Nonspecific Weaknesses in Functioning Borderlines have great difficulty tolerating frustration and coping with anxiety. In Kernberg’s framework, impulsive behavior is an attempt to diffuse this tension. Borderlines also have defective sublimation tools; that is, they are unable to channel frustrations and discomforts in socially adaptive ways. Though borderlines may exhibit extreme empathy, warmth, and guilt, these exhibitions are often rote, more manipulative gestures for display purposes only, rather than true expressions of fee...